Provider Demographics
NPI:1942335237
Name:KING MEDICAL CARE, INC.
Entity Type:Organization
Organization Name:KING MEDICAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOYLE
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:AVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-784-0500
Mailing Address - Street 1:3151 COLUMBIA BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-8889
Mailing Address - Country:US
Mailing Address - Phone:570-784-0500
Mailing Address - Fax:570-784-9563
Practice Address - Street 1:3151 COLUMBIA BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-8889
Practice Address - Country:US
Practice Address - Phone:570-784-0500
Practice Address - Fax:570-784-9563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430581174400000X
PAMD430599174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1841364890OtherNPI JENNIFER SEIDENBERG
1114960432OtherNPI PETER SEIDENBERG
ILK09793Medicare ID - Type UnspecifiedPETER H. SEIDENBERG
1114960432OtherNPI PETER SEIDENBERG